© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 CSTS -VAP Prevention Data Collection Instructions Presented by Sean Berenholtz MD, MHS, FCCM June 13, 2012 Armstrong Institute for Patient Safety and Quality

Objectives To introduce the VAP Prevention Bundle To go over the instructions for VAP Daily Rounding Form Armstrong Institute for Patient Safety and Quality 2

VAP Daily Rounding Form Armstrong Institute for Patient Safety and Quality 3

4 Basic Information Hospital: Enter the number for your hospital. Unit ID#: Enter the number of your ICU unit. Date: Enter today’s date as MM/DD/YYYY format (e.g. 06/01/2011).

Armstrong Institute for Patient Safety and Quality 5 For All Bed’s Bed #: Enter all the bed numbers on the form, whether the patient is on mechanical ventilation or not. Include empty beds. Intub/Trach & Mech Vent: Is the patient currently receiving mechanical ventilation? Enter ‘Y’ if the patient is intubated/trached and mechanically ventilated. Enter ‘N’ if the patient is not intubated /trached and mechanically ventilated. Mechanical ventilation is defined as receiving ventilator support via an ETT or tracheostomy tube. Patients treated with non- invasive ventilation would be counted as ‘N’

Armstrong Institute for Patient Safety and Quality 6 Date of Intubation Enter the date that the patient was intubated MM/DD/YYYY format (e.g. 06/01/2012) DO NOT use dates from re-intubation following self-extubation. If the patient is re-intubated following <24 hours after extubation, use first intubation date.

Time of Shift Armstrong Institute for Patient Safety and Quality 7 Enter the shift during which the data was collected. Enter ‘AM’ if completed between 12 midnight and 12 noon. Enter ‘PM’ if completed between 12 noon and 12 midnight.

Armstrong Institute for Patient Safety and Quality 8 Sub-G ETT Question Does the patient have a subglottic suctioning endotracheal tube ( Sub- G ETT)? –Enter ‘Y’ if the patient has a Sub-G ETT. –Enter ‘N’ if the patient does not have a Sub-G ETT. –Enter ‘C’ if the use of a Sub-G ETT is contraindicated.

Armstrong Institute for Patient Safety and Quality 9 Sub-G ETT Contraindication Question What is the contraindication for the use of a Sub-G ETT? –Enter ‘0’ - Other –Enter ‘1’ – Tracheostomy

Armstrong Institute for Patient Safety and Quality 10 Sub-G ETT Functionality Question Does Sub-G ETT Work? Is the subglottic tube functional? –Enter ‘Y’ if the patient has a functioning Sub-G ETT –Enter ‘N’ if the patient Sub-G ETT is not functioning. –Enter ‘N/A’ if the patient does not have Sub-G ETT

Head of Bed Question Armstrong Institute for Patient Safety and Quality 11 Is the head of the bed (HOB) at or over thirty degrees from the horizontal? –Enter ‘Y’ if the HOB is at ≥30 degrees. –Enter ‘N’ if the HOB not at ≥30 degrees. –Enter ‘C’ if HOB at ≥30 degrees is contraindicated.

Head of Bed Contraindications Armstrong Institute for Patient Safety and Quality 12 What is the contraindication to placing the head of the bed at an angle of more than or equal to 30 degrees when compared to a horizontal surface? –Enter ‘0’ - Other –Enter ‘1’ - Hypotension –Enter ‘2’ - Unstable Physiological Status –Enter ‘3’ - Low Cardiac Index –Enter ‘4’ - Cervical, thoracic or lumbar surgery or instability –Enter ‘5’ - LVAD –Enter ‘6’ – RVAD –Enter ‘7’- Intra aortic balloon pump –Enter ‘8’ – Open abdomen

Armstrong Institute for Patient Safety and Quality 13 Oral Care Question How many times has the patient had oral care without CHG in the last 24 hours? (Q4) –Enter ‘0’ if Oral Care has not been performed. –Enter ‘1’ if Oral Care has been performed once. –Enter ‘2’ if Oral Care has been performed twice. –Enter ‘3’ if Oral Care has been performed three times. –Enter ‘4’ if Oral Care has been performed four times or more. –Enter ‘C’ if the use of Oral Care is contraindicated.

Armstrong Institute for Patient Safety and Quality 14 Oral Care Definitions Oral Care without CHG includes ALL the following four interventions. 1.Perform subglottic suctioning 2.Ensure proper ETT cuff inflation 3.Clean oral cavity with suction swab using 1.5% hydrogen peroxide based solution 4.Moisturize mucosa with swab

Oral Care Contraindication Armstrong Institute for Patient Safety and Quality 15 What is the contraindication for oral care? –Enter ‘0’ - Other

Oral Care with Chlorhexidine –Question How many times in the last 24 hours has the patient had Oral Care with CHG? (Q12) –Enter ‘0’ if Oral Care with CHG has not been performed. –Enter ‘1’ if Oral Care with CHG has been performed once. –Enter ‘2’ if Oral Care with CHG has been performed twice or more. –Enter ‘C’ if Oral Care with CHG is contraindicated. Armstrong Institute for Patient Safety and Quality 16

Oral Care with Chlorhexadine –Definition Oral Care with CHG includes ALL the following four interventions; 1.Perform oral care as in “oral care without CHG” 2.Chlorhexidine a.Use alcohol free CHG b.10cc – squirt 5cc on right side of mouth between cheek and gum, being sure to get upper and lower teeth, front to back, pharynx and tongue c.Swab with toothette if needed to reach tongue/gums d.Suction out pools in mouth e.Repeat on left side with remaining 5cc f.If patient requires nystatin, give CHG and nystatin 6 hours apart g.Or, use your manufacturers directions for use Armstrong Institute for Patient Safety and Quality 17

Oral Care with Chlorhexidine –Contraindications What is the contraindication for the use of CHG in the oral care regimen? –Enter ‘0’ –Other –Enter ‘1’ If the patient is known to have an allergic or hypersensitivity reaction to chlorhexidine –Enter ‘2’ if the patient is < 2 months of age. –Enter ‘3’ if the patient might come in direct contact with CHG through the meninges. –Enter ‘4’ if all oral care is contraindicated. Armstrong Institute for Patient Safety and Quality 18

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Spontaneous Awakening Trials Question 20 Has the patient had a Spontaneous Awakening Trial (SAT) in the last 24 hours?

Spontaneous Awakening Screen and Trial Armstrong Institute for Patient Safety and Quality 21

Spontaneous Awakening Trial Contraindication 22 What is the contraindication for this patient having a Spontaneous Awakening Trial? –Enter ‘0’ –Other –Enter ‘1’ if the patient is receiving a sedative infusion for active seizures or alcohol withdrawal. –Enter ‘2’ if the patient is receiving neuromuscular blockers. –Enter ‘3’ if the patient has had evidence of active myocardial ischemia in the previous 24 h. –Enter ‘4’ if patient has evidence of increased intracranial pressure.

Spontaneous Breathing Trial Question 23 Has this patient had a Spontaneous Breathing Trial (SBT) within the last 24 hours? –Enter ‘Y’ if the patient has had a SBT within the previous 24 hours. –Enter ‘N’ if the patient has not had a SBT within the previous 24 hours. –Enter ‘C’ if the use of a SBT is contraindicated and documented in the medical record.

Spontaneous Breathing Screen 24 SBT Safety Screen: –Patients pass the screen if: They have passed the SAT trial or are responsive to verbal stimuli They have adequate oxygenation (SpO2>=88% or an F2O2 of <=50% and a PEEP <=cm H2O) They have any spontaneous inspiratory effort within a 5-min period There is an abrupt change in mental status There is currently no significant use of vasopressors or inotropes There is no evidence of increased intracranial pressure

Spontaneous Breathing Trial 25 SBT Trial: Ventilatory support is removed Patient breathes through T-tube circuit of ventilator circuit with CPAP of 5cm H2O or pressure support of < 7cm H2O. Patients pass if they don’t develop failure criteria for >= 120 minutes. –Respiratory rate of > 35 or < 8 breaths per minute or longer –Hypoxemia (SpOs =5 min) –Abrupt change in mental status –An acute cardiac arrhythmia –Two or more signs of respiratorydistress »Tachycardia »Bradycardia »Use of accessory muscles »Abdominal paradox »Diaphoresis »Marked dyspnea

Spontaneous Breathing Trial Contraindication 26 What is the contraindication for this patient having a Spontaneous Breathing Trial? –Enter ‘0’ –Other –Enter ‘1’ if the patient is receiving a sedative infusion for active seizures or alcohol withdrawal. –Enter ‘2’ if the patient is receiving neuromuscular blockers. –Enter ‘3’ if the patient has had evidence of active myocardial ischemia in the previous 24 h. –Enter ‘4’ if patient has evidence of increased intracranial pressure.

Spontaneous Breathing Trial Contraindication 27 What is the contraindication for this patient having a Spontaneous Breathing Trial? –Enter ‘0’ –Other –Enter ‘1’ if the patient didn’t pass the SAT safety screen. –Enter ‘2’ if the patient did not meet adequate oxygenation [SpO2 < 88% on an F 1 O 2 of <= 50%and a PEEP of <=3 cm H 2 O. –Enter ‘3’ if the patient did not meet criteria of no spontaneous inspiratory effort in a 5-min period –Enter ‘4’ if patient has acute agitation requiring escalating sedative doses. –Enter ‘5’ if patient has significant use of vasopressors or inotropes. –Enter ‘6’ if patient has increased intracranial pressure

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Reports % Compliance for each Process Measure Comparison Reports with other CSTS Site’s VAP Rates over Time Armstrong Institute for Patient Safety and Quality 29

Next Steps Start Data Collection –Time – We are ready when you are. –Limit Number of Data Collectors to Improve Accuracy of Data Collection Send Scanned Copies – –Fax : Armstrong Institute for Patient Safety and Quality 30

Questions ? Armstrong Institute for Patient Safety and Quality 31